Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency involving two residents. According to the facility's abuse policy, all alleged violations involving abuse, neglect, exploitation, or mistreatment must be reported immediately to the Administrator or DON, and to appropriate licensing agencies within specified timeframes. On the date in question, an activity aide observed a male resident grab the back of a female resident's head and kiss her. The female resident, who had dementia and was not her own responsible party, was unable to recall the incident and showed no signs of distress. The incident was reported up the chain of command to the RN, DON, and NHA, but no one instructed that it be reported to the State Agency, and no documentation of interviews or further investigation was made. Further review revealed that the male resident involved had a history of dementia, Alzheimer's disease, and behavioral issues, including making sexual comments and gestures toward staff and other residents. Staff interviews confirmed that the incident was witnessed and reported internally, but the DON and NHA decided not to investigate or report the event to the State Agency because there was no intent, injury, or recall of the event by the resident. The only witness, the activity aide, described the incident as a romantic kiss and stated she intervened immediately. The facility did not document any interviews or conversations about the event. Observations also showed that the activity room, where the incident occurred, was at times left unsupervised, with only one staff member present for 12 residents, including the male resident known to require close supervision due to inappropriate behaviors. Despite the facility's policy and the nature of the incident, the required reporting and investigation procedures were not followed, resulting in a failure to notify the State Agency of the alleged abuse.